Nissen fundoplication

Laparoscopic Anti-Reflux Surgery for "Heartburn"

Laparoscopic Anti-Reflux Surgery for 'Heartburn'

If you suffer from "heartburn" you may benefit from LAPAROSCOPIC ANTI-REFLUX SURGERY to treat this condition, technically referred to as gastroesophageal reflux disease (GERD). This will explain to you:

1. What gastroesophageal reflux disease (GERD) is
2. Medical and surgical treatment options for GERD
3. How this surgery is performed
4. Expected outcomes
5. What to expect if you choose to have laparoscopic anti- reflux surgery

What is Gastroesophageal Reflux Disease (GERD)?

Although "heartburn" is often used to describe a variety of digestive problems, in medical terms, it is actually a symptom of gastroesophageal reflux disease. In this condition stomach acids reflux, or accidently "back up", from the stomach into the esophagus. Heartburn is described as a harsh, burning sensation in the area in between your ribs or just below your neck. The feeling may radiate through the chest and into the throat and neck. Many adults in the United States experience this uncomfortable, burning sensation at least once a month. Other symptoms may also include vomiting, difficulty swallowing and chronic coughing or wheezing.

What causes GERD?

When you eat, food travels from your mouth to your stomach through a tube called the esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter (LES). The LES acts like a one-way valve, allowing food to pass through to the stomach. Normally, the LES closes immediately after swallowing to prevent back-up of stomach juices which have a high acid content. GERD occurs when the LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus.

What contributes to GERD?

Some people are born with a naturally weak sphincter (LES). For others, however, fatty and spicy foods, certain types of medication, tight clothing, smoking, drinking alcohol, vigorous exercise or changes in body position (bending over or lying down) may cause the LES to relax, causing reflux, or the accidental back-up of acid. A hiatal hernia (a common term for GERD) may be present in many patients who suffer from GERD, but may not cause symptoms of heartburn.

How is GERD Treated?

GERD is generally treated in three progressive steps:

1. Life Style Changes

In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing smoking and alcohol consumption, and altering eating and sleeping patterns can also help.

2. Drug Therapy

If symptoms persist after these life style changes, drug therapy may be required. Antacids neutralize stomach acids and over-the-counter medications reduce the amount of stomach acid produced. Both may be effective in relieving symptoms. Prescription drugs may be more effective in healing irritation of the esophagus and relieving symptoms.

3. Surgery

Patients who do not respond well to lifestyle changes or drug therapy, or who continually require medications to control their symptoms, will have to live with their condition or undergo a surgical procedure. Surgery is very effective in treating GERD. However, until recently this operation required a large abdominal incision resulting in significant pain after surgery and a recovery period of six weeks or greater.
Recently, this technique has been modified using laparoscopic (minimally invasive) techniques that avoid the necessity of a large abdominal incision.

How is laparoscopic anti-reflux surgery performed?

Laparoscopic anti-reflux surgery (commonly referred to as Laparoscopic Nissen Fundoplication) involves reinforcing the "valve" between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus - much the way a bun fits around a hot dog.

In a laparoscopic procedure, surgeons use small incisions (1/4 to 1/2 inch) to enter the abdomen through canulas (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the small incision, giving the surgeon a magnified view of the patient's internal organs on a television screen.
The entire operation is performed "inside" after the abdomen is expanded by pumping gas into it.

What are the expected results after laparoscopic anti-reflux surgery?

Studies have shown that the vast majority of patients who undergo the procedure are either symptom-free or have significant improvement in their GERD symptoms.

The advantage of the laparoscopic approach is that it usually provides:

  • reduced postoperative pain
  • shorter hospital stay
  • a faster return to work
  • improved cosmetic result

What are the risks of laparoscopic anti-reflux surgery?

Although the operation is considered safe, complications may occur as they may occur with any operation.

Complications during the operation may include:

  • adverse reaction to general anesthesia
  • bleeding
  • injury to the esophagus, spleen or the stomach

Complications after the operation may include:

  • infection of the wound, abdomen, or blood.
  • other less common complications may also occur.

Your surgeon may wish to discuss these with you. (S)He will also help you decide if the risks of laparoscopic anti-reflux surgery are less than the risks of leaving the condition untreated.

What happens if the operation cannot be performed by the laparoscopic method?

In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication. It is sound surgical judgement. Factors that may increase the possibility of converting to the "open" procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. The decision to convert to an open procedure is strictly based on patient safety.

Are there side effects to this operation?

Long-term side effects to this procedure are generally uncommon.

Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves within one to three months after surgery. Occasionally, these patients may require a simple procedure to expand the esophagus (endoscopic dilation) or rarely re-operation.

The ability to belch and or vomit may be limited following this procedure. Some patients complain of stomach bloating.

Rarely, some patients report no improvement in their symptoms.

What to expect before laparoscopic anti-reflux surgery

To determine if you are a candidate for laparoscopic anti-reflux surgery a thorough medical evaluation by your personal physician is necessary. Some diagnostic tests may be necessary. Your surgeon should discuss with you whether or not this operation may be a benefit to you. After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.

After midnight the night before the operation no food or liquids should be taken.

If you take medication on a daily basis, discuss this with your surgeon as (s)he may want you to take some of your medications on the morning of surgery with a sip of water. If you take aspirin, blood thinners or arthritis medication you need to discuss with your surgeon the proper timing of discontinuing these medications before your operation.

What to expect the day of surgery

You usually arrive at the hospital the morning of the operation.

A qualified medical staff member will place a small needle/catheter in your vein to dispense medication during surgery.

Often pre-operative medications are necessary.

You will be under general anesthesia - asleep - during the operation which may last several hours.

Following the operation you will be sent to the recovery room until you are fully awake.

Most patients stay in the hospital the night of surgery and may require additional days in the hospital.

What to expect after surgery

Patients are encouraged to engage in light activity while at home after surgery.

Post operative pain is generally mild although some patients may require pain medication.

Usually, anti-reflux medication is not required after surgery.

Diet after surgery beginning will consist of liquids followed by gradual advance to solid foods. No bread or meat should be eaten for the first two weeks. You should ask your surgeon about dietary restrictions immediately after the operation.

You will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, work and sexual intercourse.

If you have prolonged soreness and are getting no relief from the prescribed pain medication, you should notify your surgeon. You should call and schedule a follow-up appointment within 2 weeks after your operation.

When to call your doctor

Be sure to call your doctor if you develop any of the following:

  • Persistent fever (over 100oF)
  • Bleeding
  • Increased abdominal swelling or pain
  • Persistent nausea or vomiting
  • Chills
  • Persistent cough or shortness of breath
  • Difficulty swallowing that doesn't go away within a few weeks
  • Drainage from any incision

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